Discussion of interesting or befuddling cases related to pulmonary and critical care medicine.

Tuesday, October 04, 2005

Quick discussion on ABTx

This was an interesting consult. A 79 y/o woman with a 100-pack-year TOB Hx was admitted by her PCP with cough, dyspnea, fevers to 101 and malaise. He obtained the CxR below and started her on Levofloxacin 500 mg/day. By the second day she was still having fevers (101-102) and did not feel much better. CxR was not much different.What would you do/change at this point? What are your thoughts?

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This looks like a lobar CAP, which should be well covered with Levaquin monotherapy, although there is increasing resistance to quinolones in Streptococci. Also, there is increasing incidence of Staph in the community. But, after one day of therapy I don't think I would feel the need to change antibiotics. I would consider increasing the Levaquin dose to 750.

If the patient gets worse, or fails to improve over the next 48 hours, I'd have a low threshold to add on a penicillin/cephalosporin.

Just to take this discussion a step further, the ATS recommends use of a 3rd G Ceph and an agent for atypicals for CAP.Typically, I start patients on this cocktail because it gives me something to "fall back on" if a patient does not improve.That being said, levoflox is a pretty good drug and is probably adequate for monotherapy.f she were not better in another 48 hours (i.e. still felt lousy with fevers and perhaps other objective signs of a lack of response), I would consider a bronch with a BAL just to make sure we were not dealing with something else.

I assume patient does not have risk factors for other things - good dentition, no significant alcohol use, not immunosuppressed, no TB risk factors. If true, the recs as in above comments and then of course repeating CT in 8 weeks; if persistent, then the bronch as per Mike L's comment.

She was not initially admitted to the ICU but in a 79y/o Pt with underlying lung disease would you have a lower threshold to treat as a "severe" CAP with a regimen including a 3rd-gen Cef AND a FQ/IV macrolide?

I would have a low threshold; however, you've given no data suggesting that this is a "severe" CAP. No renal failure, mental status changes, hypotension, tachycardia, rapid respiratory rate. And (at least so far) this is only involving one lobe.

So, I have a very low threshold for escalating treatment, but failure to improve in 24 hours does not mean treatment failure...

This woman had the criteria to enter the hospital for treatment but we have not enough information to help us determine whether she should be treated in an icu as a severe pneumonia or not.If the patient has a severe cap then monotherapy with a quinolone is not sufficient as we know from the latest studies.if cap is not severe i believe we should wait for 2 days more so as to change or highten the dose of antibiotic,and it is very early to see a change on the xray